The World Health Organization (2019) has determined that patient safety is a global public health challenge. In UK clinical areas, policies and procedures are in place for the safe prescribing and delivery of blood and blood product transfusions, yet patient safety incidences continue. Undergraduate nurse education and training may provide the underlying knowledge to practitioners, while postgraduate standalone training sessions support skill development. However, over time, without regular experience, competence will diminish. Nursing students may have little exposure to transfusion practice and COVID-19 may have exacerbated this challenge with a reduction in placement availability. The use of simulation to support theory with follow-up and ongoing drop-in training sessions may help to inform practitioners and improve patient safety in the management and delivery of blood and blood product transfusion.
In 2021, almost 2 million blood products/components were supplied from the UK's NHS Blood and Transplant service (Narayan, 2022). When performed by skilled, knowledgeable and experienced staff, the risks associated with a transfusion are minimal. Ensuring the right patient receives the right blood is fundamental in limiting incidences of transfusion reaction (Soliman and Elhapashy, 2021). Transfusion error, which results in the patient receiving the wrong blood type, is one of the most frequently occurring errors relating to transfusion interventions in the UK and 81.9% of the errors are preventable according to the Serious Hazards of Transfusion (SHOT) report (Narayan, 2022).
The SHOT report (Narayan, 2022) examined transfusion data from 2020-2021 and reported 35 blood transfusion-related deaths in the UK, more than 50% of which were preventable. The Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (JPAC) (2022) identified that most incompatible blood transfusions occur due to the misidentification of the patient. The final check between patient and blood component is the last step in preventing a potentially fatal mis-transfusion. Checking the right blood is available for the right patient, at the right time and in the right place is essential in preventing transfusion errors. JPAC also stated that the blood administration process must be underpinned by three key principles: positive patient identification, good documentation and excellent communication (JPAC, 2022). Patient safety rests on the competence of staff, but also rigour in compliance with processes and competence in being able to apply processes.
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